Application for Laboratory Accreditation

NHDES-W-03-200 APPLICATION FOR LABORATORY ACCREDITATION WITH NHELAP AS A SECONDARY ACCREDITATION BODY Water Division/Drinking Water & Groundwater Bureau Environmental Laboratory Accreditation Program

RSA/Rule: RSA 485:44, Env-C 300, 2009 TNI Standards

This application must be completed as instructed. An unsigned electronic and signed & dated paper version of the completed application documents must be returned to this office. Attach additional sheets to this application if the space provided is not sufficient. Return the completed, signed and dated application form with the applicable fee to:

NH Department of Environmental Services Attn: NHELAP Program Manager PO Box 95 Concord, NH 03302-0095 Contact NHELAP if you have any questions at: [email protected] or 603-271-2998.

***NOTICE*** THIS APPLICATION IS CONSIDERED INCOMPLETE AND WILL NOT BE PROCESSED IF ANY REQUIRED DOCUMENTATION IS NOT INCLUDED WITH THIS APPLICATION.

Select: ☐ New ☐ Update ☐ Renewal NH Lab ID #: EPA Lab ID #:

Legal Name of Laboratory : Mailing Address: Street Address:

Address: Address: City or City or Town: Town: State: Zip Code: State: Zip Code:

Billing Address: Website:

Lab Telephone Address: Number: Laboratory City or Fax Town: Number: Lab Hours of State: Zip Code: Operation:

2016-12-08 (603) 271-2998 / www.des.nh.gov Page 1 of 7 NHDES-W-03-200 Lab Contact: Name: Telephone: Ext.: Email Address: Lab Director: Telephone: Ext.: QA Officer: Telephone: Ext.:

2016-12-08 (603) 271-2998 / www.des.nh.gov Page 2 of 7 NHDES-W-03-200 The following are to meet the requirements of RSA 485:46, III. (select the appropriate choice of response to each section, where applicable)

☐ The laboratory has no New Hampshire clients.

Prospective New Hampshire clients will be informed of the laboratory’s accreditation status by:

☐ Providing a copy of the laboratory’s current analyte list with all sample kits.

☐ Use of a symbol, with appropriate legend, next to the accredited analyses on the laboratory’s price list or other company literature supplied to the client.

☐ Provide a list of analyses for which the laboratory is accredited with all sample kits.

☐ Being directed to the laboratory’s current analyte list located on the laboratory website.

☐ Other method (specify):

☐ The laboratory has no outside clients (analyze only our company or municipality samples).

The analytical test report informs New Hampshire clients of the laboratory’s current accreditation status by:

☐ Providing a copy of the laboratory’s current analyte list with the test report.

☐ Use of a symbol, with appropriate legend, next to the result or the name of the analysis on the face of the test report.

☐ Providing a list of analyses for which the laboratory is currently accredited with each test report.

☐ Being directed to the laboratory’s current analyte list located on the laboratory website.

Repeat New Hampshire clients will be informed of the laboratory’s accreditation status by:

☐ Providing a copy of the laboratory’s current analyte list with all sample kits.

☐ Use of a symbol, with appropriate legend, next to the accredited analyses on the laboratory’s price list or other company literature supplied to the client.

☐ Provide a list of analyses for which the laboratory is accredited with all sample kits.

☐ Repeat clients are sent a copy of the new analyte list whenever there is a change in accreditation status.

FAILURE TO DO AS INDICATED ABOVE CAN RESULT IN SUSPENSION OF ACCREDITATION.

2016-12-08 (603) 271-2998 / www.des.nh.gov Page 3 of 7 NHDES-W-03-200 PRIMARY ACCREDITATION BODY(S)

1. Home state accrediting or certifying body:

a. Name of accreditation body:

Mailing address of accreditation body:

Contact person:

Date current accreditation expires:

b. Check the appropriate box below:

☐ My home state is (one of) my NELAP* primary accreditation body

☐ My home state is not (one of) my NELAP primary accreditation body

2. NELAP primary accreditation body:

If you have multiple primary accreditation bodies you must include a specific certificate and analyte list from each PAB**.

a. Name of accreditation body:

Contact person:

b. Name of accreditation body:

Contact person:

 National Environmental Laboratory Accreditation Program ** Primary Accreditation Body

2016-12-08 (603) 271-2998 / www.des.nh.gov Page 4 of 7 NHDES-W-03-200 NON-ACCREDITED PARAMETERS

Specify any categories, methods or analyses for which you have accreditation that you do NOT wish to have included on your NHELAP analyte list:

OWNERSHIP

A. Individual Ownership or Partnership:

Name Name

Address Address

B. Corporation (Corporation, State, City, Town, Municipality or other [where applicable]):

Name of Corporation

Address of Corporation

Date of Incorporation State

Name of Principal Officers

2016-12-08 (603) 271-2998 / www.des.nh.gov Page 5 of 7 NHDES-W-03-200 FEES FOR NEW OR RENEWAL APPLICATIONS (Ref. Env-C 303.08)

• A nonrefundable application fee shall accompany each application for a new or renewal accreditation for drinking water matrix methods, non-potable water matrix methods, solid and chemical materials matrix methods, tissue matrix methods, air matrix methods or any combination thereof. • The application fee shall be the sum of all applicable amounts listed in the Table below, subject to the explanatory notes that follow:

Accreditation Requested A B C Fees Due Base Fee $200 $200 $200 $200 Microbiology $150 $175 $225 Pathogen analysis $150 $175 $225 Limited inorganic chemistry (only)* $250 $275 $325 Limited organic chemistry (only)** $250 $275 $325 Limited inorganic chemistry* $150 $175 $225 Limited organic chemistry** $150 $175 $225 One or two metals $150 $175 $225 Microbiology and limited inorganic chemistry $200 $225 $300 Microbiology and one or two metals $200 $225 $300 Microbiology, limited inorganic chemistry, and one or two metals $300 $325 $450 Metals $425 $525 $650 Inorganic chemistry $425 $525 $650 Metals and Inorganic chemistry $500 $600 $725 Organic chemistry $500 $600 $725 Radiological chemistry $300 $325 $450 Whole Effluent or Sediment Toxicity Testing $300 Whole Effluent and Sediment Toxicity Testing $450 Radon in Water analysis $150 Additional fee for non-standard performance-based or laboratory- $100 $125 $150 developed methods Sample preparation method (per method) $25 $25 $25 Total $ Fee Due to NHELAP

• The following explanatory notes apply to the Table above: (1) Column A applies to laboratories seeking accreditation for: a. Drinking water matrix methods only; b. Non-potable water matrix methods other than SW-846 methods (non-SW-846 methods) only; c. Non-potable water matrix SW-846 methods only; d. Tissue matrix methods only; e. Air matrix methods only; or f. Solid and chemical materials matrix methods only. (2) Column B applies to laboratories seeking accreditation for any 2 matrix/method combinations listed in (1), above; (3) Column C applies to laboratories seeking accreditation for any combination of 3 or more matrix/methods from (1), above. * Limited Inorganic Chemistry is defined as 6 or fewer matrix/method/analyte combination analyses for inorganic analytes other than metals. ** Limited Organic Chemistry is defined as 6 or fewer matrix/method/analyte combination analyses for organic analytes.

2016-12-08 (603) 271-2998 / www.des.nh.gov Page 6 of 7 NHDES-W-03-200 Make the application fee check payable to Treasurer, State of New Hampshire. AND Deliver the complete, signed and dated application package with the fee to NHDES / Attn: NHELAP Program Manager, P.O. Box 95, Concord, NH 03302-0095. AND File the application form and all supporting documentation electronically.

Applications for accreditation shall not be processed nor accreditation granted if the correct application fee, a copy of a Purchase Order (PO) document or a copy of a Requisition Form is not received by NHELAP / NHDES.

Contact NHELAP if you need an invoice form for billing purposes.

SIGNATURE REQUIRED (Ref. Env-C 303.02)

The application form must be signed and dated by the individual designated by the applicant.

By signing this application, the signer certifies that: (1) The information provided is true, complete and not misleading to the knowledge and belief of the signer; and (2) The signer understands that: a. Any accreditation issued based on false, incomplete or misleading information shall be subject to denial, suspension or revocation; and b. The signer is subject to the penalties specified in New Hampshire law, currently RSA 641:3, for making unsworn false statements.

DATE (above) Title

Typed Name of Authorized Agent Authorized Agent Signature

An authorized agent or authorized company representative is a person who is a principal executive officer or other corporate officer with signatory powers as per the company's by-laws or per a vote of the directors if the company is a corporation; a general partner or proprietor if the company is a partnership or sole proprietorship respectively; or a duly authorized representative, the individual designated on the permit application (i.e. an application for accreditation ) or permit cover page, if such representative is responsible for the overall operation of the facility (possibly the Lab Director) and has the authority to sign contracts, permits, permit applications, monitoring results and other documents in the company's name and otherwise bind the company.

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